Arlyn C.

Mendenilla, RN
 Nurses encounter clients with respiratory
problems in virtually every area of practice and
virtually every practice setting.

Nursing care of clients with respiratory

problems may range from prevention of the
spread of common cold in a school setting to
sustaining the life of a client in respiratory
failure in the intensive care unit.
 Thorax identifies the portion of the body
extending from the base of the neck
superiorly to the level of the diaphragm.

The thoracic cage is constructed of the

sternum, 12 pairs of ribs, 12 thoracic
vertebrae, muscles, and cartilage.

The thorax consists of the anterior thoracic

cage and the posterior thoracic cage.
 The thoracic cavity consists of the
mediastinum and the lungs.

The lungs are cone-shaped, elastic structures

suspended within the thoracic cavity.

The apex of the lungs extends slightly above

the clavicle.

The base of the lungs is at the level of the

diaphragm.
 Before beginning the assessment, the nurse
must be familiar with series of imaginary
lines on the chest wall and be able to locate
the position of each rib and some spinous
processes.

These landmarks help the nurse to identify

the position of underlying organs ( ex. Lobes
of the lung) and to record abnormal findings.
A B C
 Posterior chest landmarks and underlying lungs
Anterior chest landmarks and underlying lungs;

Lateral chest landmarks and underlying lungs.

 In adults, the
thorax is oval.
Its anterioposterior
diameter is half its
traverse diameter.
Overall shape is
eleptical; that is, its
diameter is smaller
at the top than at
the base.
Chest deformities: A, pigeon chest; B, funnel chest; C, barrel chest;
D, kyphosis; E, scoliosis.
 Normal breath sounds
Vesicular
Broncho vesicular
Bronchial

Adventitious breath sounds

Crackles (rales) best heard on inspiration
Gurgles (rhonchi) best heard on expiration
Friction rub inspiration and expiration
Wheeze - best heard on expiration
 Planning

For efficiency, the nurse usually examines the posterior

chest first, then the anterior chest wall.
For posterior and lateral chest examinations, the client
is uncovered to the waist and in a sitting position.
The sitting or lying position maybe used for anterior
chest examination.
The sitting position is preferred because it maximizes
chest expansion.
Good lighting is essential, especially for chest expansion
Assemble equipment:
Stethoscope
Skin marker/pencil
Centimeter ruler

Assessment of thorax and lungs is not

delegated to nursing aide
1. Introduce yourself and verify the clients
identity. Explain to the client what you are
going to do, why it is necessary, and how the
client can cooperate.
2. Perform hand hygiene and observe other
appropriate infection control procedures.
3. Provide for client privacy.
4. Inquire if client has any history of the following:
Family history of illness, including cancer
Allergies
Tuberculosis
Lifestyle habits, such as smoking, and occupational
hazards
Any medications being taken
Current problems such as swellings, coughs, wheezing,
pain
 Assessment Normal Findings Deviation from Normal

Posterior thorax

5. Inspect the shape, Anteroposterior to Barrel chest;

color and symmetry transverese diameter increased
of the thorax from ratio of 1:2 anteroposterior to
posterior and transverse diameter
lateral views.
Compare the Pink Pallor, cyanosis
anteroposterior
diameter to the Chest symmetric Chest asymmetric
transverse
diameter.
 Assessment Normal Findings Deviation from Normal
6. Inspect the spinal
alignment for
deformities.
Have the client stand. Spine vertically Exaggerated spinal
From a lateral aligned curvatures
position, observe the ( kyphosis, lordosis)
three normal
curvatures: cervical,
thoracic, and lumbar.
To assess for lateral Spinal column is Spinal column
deviation of the spine straight, right and deviates to one side,
(scoliosis), observe left shoulders and often accentuated
the standing client hips are the same when bending over.
from the rear. Have height Shoulder or hips not
the client bend even
forward at the waist
and observe from
behind.
 Assessment Normal Findings Deviation from Normal
7. Palpate the
posterior thorax.
For clients who have no Skin intact, uniform Skin lesions: areas of
respiratory complaints, temperature hyperthermia
rapidly assess the
temperature and
integrity of all chest
skin.

For clients who do have Chest wall intact; no Lumps, bulges;

respiratory complaints, tenderness; no masses depression; areas of
palpate all chest areas tenderness; movable
for bulges, tenderness, structures (ex. Rib)
or abnormal
movements. Avoid deep
palpation for painful
areas, especially if a
fractured rib is
suspected.
 Assessment Normal Findings Deviation from Normal

8.Palpate the
posterior chest for
respiratory
excursion.
Place the palms of Full and symmetric Asymmetric and/or
both your hands chest expansion. When decreased chest
over the lower the client takes a deep expansion
thorax, with your breath, your thumbs
thumbs adjacent to should move apart an
equal distance at the
the spine and your
same time; normally
fingers stretched the thumbs separate 3
laterally. Ask the to 5 cm ( 1 to 2 in)
client to take a deep during deep
breath while you inspiration
observe the
movement of your
hands and any lag in
movement.
9. Palpate the chest for vocal
(tactile) fremitus.
Place the palmar surfaces of
your fingertips or the ulnar
aspect of your hand or closed
fist on the posterior chest,
starting near the apex of the
lungs.
Ask the client to repeat such
words as blue moon or one,
two, three, or 99
Bilateral symmetry of vocal Decreased or absent
fremitus. fremitus (asso. Wd
Fremitus is heard most pneumothorax)
clearly at the apex of the
heart
Low-pitched voices of Increased fremitus (asso.
males are more readily wd consolidated lung
palpated than the higher tissue, as in pneumonia
pitched voices of females

Repeat the two steps, moving

your hands sequentially to the
base of the lungs.
Compare the fremitus on both
lungs and between the apex
and the base of each lung,
either 1) using one hand and
moving it from one side of the
client to the corresponding
area on the other side or 2)
using two hands that are
placed simultaneously on the
corresponding areas of each
side of the chest.
 Assessment Normal Findings Deviation from
Normal
10. Percuss the thorax. Percussion notes Assymetry in
ask the client to bend resonate, except over percussion
the head and fold the scapula
arms forward across Areas of dullness
the chest. Lowest point of or flatness over
resonance is at the lung tissue (asso.
Percuss in the
diaphragm With consolidation
intercostal spaces at of lung tissue or a
about 5 cm (2in) Percussion on the rib mass or fluid.
intervals in systematic normally elicits
sequence dullness Hyperresonance is
Compare one side of heard over
the lung with the emphysematous
other lungs.
Percuss the lateral
every few inches,
starting at the axilla
and working down to
the eight rib
 Assessment Normal Findings Deviation from
Normal
11. Percuss for diaphragmatic excursion.

Ask the client to take a deep breath and Percussion 3 to 5 Restricted

hold it while you percuss downward along cm bilaterally in excursion (asso.
the scapular line until dullness is produced at women and 5 to 6 Wd lung disorder)
the level of the diaphragm. Mark this point cm in men
with a marking pencil, and repeat the
procedure on the other side of the chest. Diaphragm is
usually slightly
higher on the
right side

Ask the client to take a few normal breaths

and then expel the last breath completely
and hold it while you percuss upward from
the marked poingt to assess and mark the
diaphragmatic excursion during deep
expiration on each side

Measure the distance between two marks

 Assessment Normal Deviation from
Findings Normal
12. Auscultate the chest using Normal breath Adventitious
the flat-disc diaphragm of the sounds breath sounds
stethoscope. sounds

No breath sounds
Use the systematic zigzag
procedure used in percussion.
Ask the client to take slow,
deep breaths through the
mouth. Listen at each point to
the breath sounds during a
complete inspiration and
expiration.
Compare findings at each
point with the corresponding
point on the opposite side of
the chest.
 Assessment Normal Findings Deviation from Normal
Anterior Thorax

13. Inspect Quiet, rhythmic, and Abnormal breathing

effortless respirations pattern tachypnea,
breathing bradypnea, apnea etc.
patterns.(ex.
RR, rhythm)
14. Inspect the Costal angle is 90, and Costal angle is widened
the ribs insert into the assocaited with COPD
costal angle spine at approximately
and the angle at at 45 angle

which the ribs

enter the spine.

15. Palpate the

anterior chest.
 Assessment Normal Findings Deviation from
Normal
17. Palpate tactile fremitus in Same as posterior Same as posterior
the same manner as for the vocal fremitus; vocal fremitus;
posterior chest.
If the breasts are large and Fremitus is normally
cannot be retracted adequately decreased over heart
for palpation, this part of the and breast tissue
examination usually is omitted.
18. Percuss the anterior chest Percussion notes Asymmetry in
systematically. resonate down to the percussion notes
sixth rib at the level
of diaphragm
Begin above the clavicles in the But are flat over areas Areas of dullness or
supraclavicular space, and of heavy muscle and flatness over lung
proceed downward to the bone tissue
diaphragm.
Compare one side of the lung ,dull on areas over
to the other. the heart & the liver
Displace female breasts for and tympanic over
proper examination. the underlying
stomach
 Assessment Normal Findings Deviation from
Normal
19. Auscultate the Bronchial and tubular Adventitious
breath sounds sound
trachea.
20. Auscultate the Bronchovesicular and Adventitious
anterior chest. vesicular breath sound
sounds
Use the sequence used
in percussion, beginning
over the bronchi
between the sternum
and the clavicles.
Document findings in
the client record using
forms or checklist
supplemented by
narrative notes when
appropriate.
 In infants thorax is
rounded; that is, the
diameter from the
front to the back
(anteposterior) is
equal to the
transverse diameter.

It is also cylindrical,
nearly equal diameter
at the top and the
base.
 Also known as
pectus carinatum.
A narrow transverse
diameter, an
increase
anteroposterior
diameter, and a
protruding sternum.
 Sternum is
depressed,
narrowing the
anteroposterior
diameter.
Also known as
pectus excavatum.
5 8

What are the

four types of
Adventitious
Breath Sounds?
9 13

Enumerate the
structures
that makes up
the thoracic
cage.
 14 18

What are the 5

imaginary
lines of the
anterior chest
 What is the
preferred
position during
chest
examination?
 What is the
normal
overall shape
of the thorax?